Antenatal features of Down syndrome

Last revised by Ayush Goel on 10 Sep 2021

Antenatal screening of Down syndrome (and other less common aneuploidies) should be available as a routine component of antenatal care. It allows families to either adjust to the idea of having a child with the condition or to consider termination of pregnancy.

For a general description of Down syndrome and its postnatal manifestations, please refer to the article on Down syndrome.

There is a strong association between the incidence of Down syndrome and maternal age. Background risk based on maternal age is incorporated into both the serum screening based risk calculations and into the calculation of increased risk in the presence of a soft marker in 2nd trimester (see below).

Please refer to the antenatal screening for a general discussion of the avenues of screening and diagnosis in the antenatal period.

Combined serum screening has an approximately 85% detection rate, with 5% false positive rate 8

  • maternal beta hCG
    • higher than chromosomally normal fetuses
    • the difference increases with gestation
  • PAPP-A
    • lower than chromosomally normal fetuses 
    • difference decreases with gestation: therefore not commonly used as a second-trimester test

A triple screening/quadruple screening is done in high-risk cases. However combined screening test is most preferred. Detection rate for trisomy 21 is at approximately 80% with a false positive rate of ~5% 8.

  • maternal free beta-hCG: higher than chromosomally normal fetuses
  • inhibin A: higher than chromosomally normal fetuses
  • AFP: lower than chromosomally normal fetuses 
  • unconjugated estriol (uE3): lower than chromosomally normal fetuses 

Nuchal translucency: thickness depends on the size of the fetus (CRL), but in general it is considered abnormal if >3 mm.

There is evidence that the inclusion of nasal bone measurement improves the specificity of 1st trimester data 5.

Ductus venosus flow is another parameter that has been reported to further increase the sensitivity of 1st trimester screening 12.

Approximately 30% of babies with Down syndrome have detectable abnormalities on the mid-trimester ultrasound 1.  

Soft markers are sonographic findings that do not in themselves cause any adverse outcomes. However, they are seen more frequently in fetuses with an abnormality.  This article addresses the soft markers that are specific to Down syndrome. For a general discussion, please refer to the article on soft markers.  

The markers are as follows 13:

In the presence of soft markers, the risk of Down syndrome is recalculated as new risk = baseline risk x likelihood ratio (LR). The new LR is calculated by multiplying all positive LRs (of markers present) and all negative LRs (of markers absent).

Note: if a single marker is present, then isolated LR is considered.

The following may be present in association with Down syndrome:

Other features that may be present, but are neither a structural abnormality or a validated soft marker 8

Some fetuses can develop transient abnormal myelopoiesis (TAM) particularly towards the 3rd trimester and can then develop fetal hepatomegaly 11.

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Cases and figures

  • Case 1: Down syndrome - antenatal
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